ARNOT HEALTH POLICY AND PROCEDURE MANUAL POLICY #:...
Transcript of ARNOT HEALTH POLICY AND PROCEDURE MANUAL POLICY #:...
ARNOT HEALTH
POLICY AND PROCEDURE MANUAL
POLICY #: TR210.0
DATE OF ISSUE: 4/10/17
DATE(s) OF REVISION: N/A
APPROVAL: ____________________________________
Dr. Yafei Wang M.D.
Medical Director of SJH Laboratory
____________________________________
Dr. Terence Lenhardt, M.D., PhD
Medical Director of AOMC & IDMH
Laboratories
Medical Director of Transfusion Services
FACILITIES COVERED:
AOMC AMS SJH IDMH
TITLE: Collection of Blood Bank Samples
ORIGINATOR: Laboratory – Blood Bank
PURPOSE
Positive patient identification is critical in the collection of blood bank samples. This procedure defines
the appropriate steps for collection of these samples.
The main steps of the process are outlined in this policy. There are unit specific workflows as appendices
SAMPLE REQUIREMENTS
Full Pink top EDTA tube, or a lavender microtainer for NICU samples
Lab Order label must be on the sample
Two collector codes must be on the sample
Home draw Patients must have Verification form completed
Time of draw must be on the sample
If any of the requirements are not met, the sample will be rejected and must be redrawn
PROCEDURE
1. Order for Type and Screen or Type and Crossmatch is placed in Quadramed
2. Obtain the lab order labels
a. If they are unusable, get lost, or can’t be used for any reason, contact the Blood Bank for a
replacement label
b. In the Event of computer downtime: Place a chart label on the sample with both
Quadramed Codes and time of draw written on it. THIS IS THE ONLY TIME IT IS
ACCEPTABLE FOR A BLOOD BANK SPECIMEN TO BE SENT WITH ONLY A
CHART LABEL. 3. Positive Patient Identification at Sample Collection
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a. Two people must be involved in the patient identification at the time of sample collection
a. One of the two must be licensed (RN, LPN, MD, DO, PA, Nurse Practitioner or Med.
Tech from the Lab) b. Ask the patient their name and date of birth
c. For non-verbal patients, the patient’s family or Nurse must confirm ID
d. One person verifies the name and date of birth against the registration bracelet, outpatient
requisition or Chart Photo/MARS for SNF patients
e. The second person verifies the name and date of birth against the lab label
f. If there is ANY discrepancy between the patients verbal response, the label or the
Requisition/wristband STOP. Blood sample cannot be drawn until the
discrepancy is resolved. g. After positive patient identification, collect blood sample, write both QuadraMed codes on
the label and the time of collection
h. Place lab order label on the sample before leaving the patient
4. Send Sample to the Laboratory
5. Patients with no previous Blood Bank History
a. Patients blood type must be verified with a second sample drawn at a different time than
the first sample
b. For all nursing units/patient care areas EXCEPT the AOMC and SJH ER, every attempt
will be made to use a previously drawn lavender tube
c. A laboratory Phlebotomist will obtain the second sample for Emergency Room patients at
both AOMC and SJH
a. For outpatient testing that will not result in the administration of a blood product: a
second sample is not required. (Prenatal Blood Bank, Outpatient ABORh, DAT,
Antenatal Rhogam)
b. NICU:
All cord bloods that do not have a full cord blood workup ordered will have
a Blood Type Confirmation performed.
If the neonate needs blood in the future, the type and screen or type and
crossmatch must be drawn with the Double Verification process.
If a cord blood was not sent, every attempt will be made to use a previously
collected sample, but if one is not available a sample must be drawn. It will
just be a regular blood draw with a lavender microtainer and only one
QuadraMed Code. Chart Labels are acceptable. 6. If a sample must be collected:
a. The confirmation cannot be ordered in QuadraMed and will be ordered by the Blood Bank
b. The lab order label may be sent to the patient’s location or the sample may be sent with
chart labels in emergent situations
c. Confirmation Sample does not require 2 person verification, will be in a lavender or pink
tube and chart labels are acceptable
d. For patients that are difficult to draw, only a very small sample is necessary and can be a
fingerstick sample collected in a lavender microtainer
e. The patient will only be able to receive O Negative red blood cells until this confirmation is
complete – due to the precious nature of O negatives red blood cells, this sample should be
collected ASAP
7. Some areas of the hospital have work flows that are unique. Please refer to the appendixes for
department/nursing unit specifics
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Appendix I: Regular Workflow (AOMC L&D, MAT, ICU, Med Surge Units)
Appendix II: NICU
Appendix III: Operating Room/Recovery
Appendix IV: Pre-Admission Testing
Appendix V: Outpatient Phlebotomy
Appendix VI: AOMC Emergency Room
Appendix VII: SNF/TCU
Appendix VIII: SJH Emergency Room
Appendix IX: SJH Infusion Center and Falck Cancer Center
Appendix X: SJH Mixed Medical and C4 Unit
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APPENDIX I: General Workflow: ICU, Med/Surg, MAT, L&D
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APPENDIX II: NICU Workflow
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APPENDIX III: Operating Room/PAR Workflow
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APPENDIX IV: Pre-Admission Testing (PAT) Workflow
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APPENDIX V: Outpatient Phlebotomy Workflow
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Appendix VI: AOMC Emergency Room
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Appendix VII: Skilled Nursing Floor and Transitional Care Unit (TCU)
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Appendix VIII: SJH Emergency Room
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Appendix IX: SJH Infusion Center and Falck Cancer Center
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Appendix X: SJH Mixed Medical and C4 Units
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Appendix XI: Home Phlebotomy and Satellite Phlebotomy Draw Stations (Only 1
phlebotomist)